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APPLICATION FOR SANITATION PERMIT Permit No. ..•��^4.7__„ (Complete in Duplicate) Date Issued -__ ,d- Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 54 JOB ADDRESS AND L C IN----- - -------------------------------------------------•---------------------------------- Owner's Name ;. .� _ --------- Phone----•----------- ----------------- -------------- Address----------p - 'f Q , 74 Contractor's Name - ----------------------------- Phone P/1J Installation will serve: Residence Apartment House ❑ Commercial ❑ Trailer Court p Motel ❑ Other ❑ Number of living units: _j0I Number of bedrooms _AIIIIII_ Number of baths ---e__ Lot size h__ -------------------------------- Water Supply: Public system ['Community system ❑ Private ❑ Depth to Water Table £t, Character of soil to a depth of 3 feet: Sand ❑ Gravel ❑ Sandy Loam ❑ Clay Loam ❑ Clay ❑ Adobe &-TIerdpan ❑ Previous Application Made: Yes ❑ No [Er'-New Construction: Yes [ (Flo ❑ FHA/VA: Yes Ft-'No ❑ TYPE OF INSTALLATION AND SPECIFICATIONS: (No septic tank or'cesspool permitted if,-public sewer is available within 200 feet.) Septic Tank: Distance from nearest weli--?1026-6'_'Distance/from f/o�undation-___Zp-------- Material---- S�_ _ No. of compartments--.__i _______----__.5ize_y �?_,f __7R_ If -----Liquid --- ---__----Ca acis+ �__-_-- r ¢ p ty--- - Disposal Field: Distance from nearest weli_'.0�/.Distance from foundation__-/X--_. -.Distance to nearest lot lin__ - sa1�, Number of lines-------1------- ---- ----_ ---Length of each line------.-_____-,___.Width of trench------, ------------_-- - Type of filter materiae__--- -Depth of filter material_-_f��------Total length_-_____r _' ------------- Seepage Pit: Distance to nearest well____ _ .�-Distance Qfrom f�ndation----r��-------Distance to nearest loft line_-._-�_--_ Number of pits_-_-_�_____________Lining material_ - - --.-Size: Diameter_ . _//- ' Depth---.A-Q------------------- Cesspool: Distance from nearest well--------------- from foundation--------------------Lining material------------------------------------- I Size: €3iameter-------------------------- -------- - Depth-----------------------------------------------------Liquid Capacity--------------------------.gals. Privy: Distance from nearest well----------------------------------------________Distance from nearest building------------------------------------------ Distance __-----__-_________---_______ - Distance to nearest lot line-------------------------------- ------------------------ ' I --------------------------------- Remodeling and/or repairing (describe)----------------&vr--4-- a ------ --- - - - --- - - ----••--------------------------------------- ------------------------- -------------------------------------------------------------•---------------------------------------- I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County ordinances, State laws, and rules and re ulations of the San Joaquin Local Health District, (Signed)----------- " I � Contractor ' By:------------------------------ - Ti+le --------- ---------------- - ( f ` (Plot plan, showing size of lot, lea n of system in relation to wells, buildings, etc., can be placed on rev side). FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ----------------- DATE C REVIEWED BY------------------------------------------------- ------ DATE BUILDING PERMIT ISSUED --------------------------- DATE------------------ -------------------- Alterations and/or recommendations________ _____..._ _____-..__---------___---_-- --------5� % T------/ z.e 1L_c W__, �,�,r � �� 'c� = -------------�h;VAct_I C ----------------------- ----------- --------------------------------- ----------------------------- FINAL INSPECTION BY-------------- -------•------- ------ Date-------=- ,pZ! -- --------------------------------- AN JOAQUIN LOCAL HEALTH DISTRICT 130 South American Street 300 West Oak Sfreet * 132 Syeamora Street 814 North "C" Street Stockton, California Lodi, California Manteca, California Tracy, California ES-9-2M . Revised 1.57 F.P.CO.